Bipolar and Related Disorder Due to Another Medical Condition
DSM-5 Diagnostic Criteria A'''. A prominent and persistent period of abnormally elevated, expansive, or irritable mood and abnormally increased activity or energy that predominates in the clinical picture. '''B. There is evidence from the history, physical examination, or laboratory findings that the disturbance is the direct pathophysiological consequence of another medical condition. C'''. The disturbance is not better explained by another mental disorder. '''D. The disturbance does not occur exclusively during the course of a delirium. E'. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning, or necessitates hospitalization to prevent harm to self or others, or there are psychotic features. ''Specify if: * '''With manic features: Full criteria are not met for a manic or hypomanic episode. * With manic- or hypomanic-like episode: Full criteria are met except Criterion D for a manic episode or except Criterion F for a hypomanic episode. * With mixed features: Symptoms of depression are also present but do not predominate in the clinical picture. Note: Include the name of the other medical condition in the name of the mental disorder (e.g., bipolar disorder due to hyperthyroidism, with manic features). The other medical condition should also be listed separately immediately before the bipolar and related disorder due to the medical condition (e.g., hyperthyroidism; bipolar disorder due to hyperthyroidism, with manic features). Differential Diagnosis Symptoms of delirium, catatonia, and acute anxiety It is important to differentiate symptoms of manic from excited or hypervigilant delirious symptoms; from excited catatonic symptoms; and from agitation related to acute anxiety states. Medication-induced depressive or manic symptoms An important differential diagnostic observation is that the other medical condition may be treated with medications (e.g., steroids or alpha-interferon) that can induce depressive or manic symptoms. In these cases, clinical judgement using all of the evidence in hand is the best way to try to separate the most likely and/or the most important of two etiological factors (i.e., association with the medical condition vs. a substance/medication-induced syndrome). The differential diagnosis of the associated medical conditions is relevant but largely beyond the scope of the present manual. Related Criteria For the specifier "with manic- or hypomanic-like episode," the criteria for either a manic episode or a hypomanic episode must be met, except for Criterion D of a manic episode or Criterion F of a hypomanic episode: Manic Episode A'''. A distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased goal-directed activity or energy, lasting at least 1 week and present most of the day, nearly every day (or any duration if hospitalization is necessary). '''B. During the period of mood disturbance and increased energy or activity, three (or more) of the following symptoms (four if the mood is only irritable) are present to a significant degree and represent a noticeable change from usual behavior: # Inflated self-esteem or grandiosity. # Decreased need for sleep (e.g., feels rested after only 3 hours of sleep). # More talkative than usual or pressure to keep talking. # Flight of ideas or subjective experience that thoughts are racing. # Distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli), as reported or observed. # Increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation (i.e., purposeless non-goal-directed activity). # Excessive involvement in activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments). C'''. The mood disturbance is sufficiently severe to cause marked impairment in social or occupational functioning or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features. '''D. The episode is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication, other treatment) or to another medical condition. (Note: A full manic episode that emerges during antidepressant treatment medication, electroconvulsive therapy but persists at a fully syndromal level beyond the physiological effect of that treatment is sufficient evidence for a manic episode and, therefore, a bipolar I diagnosis.) Hypomanic Episode A'''. A distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased goal-directed activity or energy, lasting at least 4 consecutive days and present most of the day, nearly every day. '''B. During the period of mood disturbance and increased energy or activity, three (or more) of the following symptoms (four if the mood is only irritable) are present to a significant degree and represent a noticeable change from usual behavior, and have been present to a significant degree: # Inflated self-esteem or grandiosity. # Decreased need for sleep (e.g., feels rested after only 3 hours of sleep). # More talkative than usual or pressure to keep talking. # Flight of ideas or subjective experience that thoughts are racing. # Distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli), as reported or observed. # Increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation. # Excessive involvement in activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments). C'''. The episode is associated with an unequivocal change in functioning that is uncharacteristic of the individual when not symptomatic. '''D. The disturbance in mood and the change in functioning are observable by others. E'''. The episode is not severe enough to cause marked impairment in social or occupational functioning or to necessitate hospitalization. If there are psychotic features, the episode is, by definition, manic. '''F. The episode is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication, other treatment). (Note: A full hypomanic episode that emerges during antidepressant treatment medication, electroconvulsive therapy but persists at a fully syndromal level beyond the physiological effect of that treatment is sufficient evidence for a hypomanic episode diagnosis. However, caution is indicated so that one or two symptoms increased irritability, edginess, or agitation following antidepressant use are not taken as sufficient for diagnosis of a hypomanic episode, nor necessarily indicative of a bipolar diathesis).